# NTSB LAX96FA169: Cameron A-210, N6085C, Cave Creek, AZ, April 15, 1996 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 15, 1996, 07:49 local (14:49 UTC) - Place: Cave Creek, AZ - Coordinates: 33.880931, -111.909439 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.8809&lon=-111.9094&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 4 serious, 3 minor - Status: Completed, report January 17, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 29272 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX96FA169 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29272/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=29272 - Page: https://openairdocs.org/ntsb/LAX96FA169 ## Probable cause the pilot's failure to follow the flight manual procedure by not turning off the burner's pilot shutoff valves. Factors relating to the accident were: the installation of improper (unapproved wooden) upright rods by company maintenance personnel, subsequent failure of the upright rods, and the manufacturer's unclear information concerning the replacement parts. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, landing - miscellaneous,lighter-than-air craft/equipment - unapproved (contributing factor) - maintenance,installation - improper, company maintenance personnel (contributing factor) - charts/other manuals - inadequate - information unclear, manufacturer (contributing factor) - miscellaneous,lighter-than-air craft/equipment - failure (contributing factor) - Fire, landing - procedures/directives - not followed, pilot in command (cause) - fuel supply - improper use of, pilot in command (cause) ## Analysis A flight of four balloons was landing in a prearranged open area after completion of a sight-seeing local area tour. During the landing, the pilot of N6085C did not turn off the fuel tanks or the pilot light burners as required by the flight manual for high wind landings. During the landing, the balloon's basket drug about 422 feet along the ground before it tipped onto its side. The basket then dragged about 69 feet before the previously installed wooden upright rods broke and the basket flipped inverted and came to a stop. After the balloon had stopped, someone inadvertently actuated the burner's blast valve, and a fire immediately erupted. All but one of the occupants evacuated the basket. The operator reported that on the day preceding the accident, the nylon upright rods broke during inflation of the balloon, and they were replaced with wooden upright rods. Examination showed no evidence of any preexisting fuel tank system malfunction or failure. The manufacturer's proprietary drawings showed that only nylon or lexan rods were to be used; this requirement, however, was not specifically noted in the balloon's flight or maintenance manual. The Cameron Balloon Parts Catalog specifically required the approved upright rods. ## Factual narrative History of Flight On April 15, 1996, at 0749 hours mountain standard time, a Cameron A-210 hot air balloon, nosed over and erupted into flames after being dragged 485.2 feet and becoming inverted while landing in an open field near Phoenix, Arizona. The pilot was completing a local area visual flight rules sight-seeing flight. The balloon, operated by Get Carried Away, Scottsdale, Arizona, was destroyed by the postimpact fire. The certificated commercial pilot and two passengers sustained minor injuries, one passenger sustained fatal injuries, and five passengers sustained serious injuries. One of the seriously injured passengers died on April 28, 1996. Visual meteorological conditions prevailed. The flight originated from an open field at Cave Creek, Arizona, at 0650. Some of the passengers in the accident balloon told Phoenix Police Department detectives that the they were participating in a General Motors, Chevrolet Division, top 100 dealers award winning trip promotion. The balloon ride was part of the promotional package. The passengers said they were bused from their hotel to the departure site and boarded the accident balloon. Other passengers boarded three other balloons. After departing on the flight they flew directly to the accident area. In preparation for landing, the pilot briefed the passengers that it was going to be a "breezy, rough landing" and they should crouch down and hold onto something and that the balloon might tip over. One passenger said that the pilot established two landing plans. The first plan was to have the passengers kneeling down as they landed, and the other plan was to have them standing up. The pilot told them to kneel down during the approach for landing. The balloon approached the landing area from the northeast and touched down beyond the fence line; the balloon did not hit the fence. As the balloon flew over the canal on the approach, the pilot was pulling a "red line" (the red line is used to let out the gaseous air and deflate the envelope). After touchdown, the balloon drug across the ground and the pilot continued to pull on the red line. The basket then tipped onto its side. Moments later, the basket tipped over from its side to inverted. After the basket was inverted, a passenger said he heard the burners go off and then saw that a "girls hair" was on fire. Other people arrived at the basket and helped the passengers evacuate. Safety Board investigators interviewed Get Carried Away (hereafter referred to as the company) ground crew chief at the accident site on April 15, 1996. The crew chief said he saw the balloon land and, according to company policy, ran to the balloon and latched onto the balloon as it touched down to help weigh it down and stabilize it. The crew chief attempted to assist the pilot pull the red line as the basket drug along the ground when it "dog housed (the basket became inverted)" about 8 feet before it caught fire. Two other balloons landed near the accident balloon a few minutes before the accident. Both pilots said that they saw the accident balloon land with the short side of the basket pointed toward the direction of travel. They said that they landed with the short side of the basket pointed in the direction of travel. Both pilots also said that the accident balloon's landing appeared to be normal. The company's director of operations said that three of the four nylon upright rods broke while inflating the accident balloon on the morning preceding the accident. Three of the four upright rods were replaced with wooden rods. The owner of the company said that a person from the company went to Arizona Hot Air Repair to obtain new upright rods. The owner of the repair station told him that wooden poles would suffice, and that new uprights could be delivered to Get Carried Away before the next morning's flight. The person asked the repair station owner to deliver them in the morning. The company's director of operations said, however, that the repair station (Arizona Hot Air Repair) owner did not say that the use of wooden poles would suffice. The director of operations attributed the statement to the mechanic who performed the last annual inspection; the mechanic was also one of the pilot's who landed before the accident balloon. The mechanic said in a telephone interview that it would be better to use wooden poles than no poles at all, even though the flight manual allows the flight to be accomplished without any poles. On the morning of the accident the repair station owner went to the wrong location to deliver the upright rods. The company's owner said that the uprights were not the correct length for use in their balloon. The repair station said that on April 14, 1996, he observed the pilot abort the inflation of the accident balloon between 0615 and 0630. At 0730, another pilot from the company (also the mechanic who did the last annual inspection) told him that three of the four flexi-rigid nylon poles had broken earlier during a "hot air inflation." The repair station owner told the pilot/mechanic that he had some flexi-rigid nylon poles at his shop and that he would replace and deliver them to the Jomax site on April 15, 1996, before the flying activities started. Later that day (April 14, 1996), the company's director of operations called and told him that three flexi-rigid nylon poles had broken. He told the director of operations that he was aware of the situation and that he would bring the poles to the Jomax site the next morning. He also told him that he would cut the poles to the required length, but the director of operations said that he would cut the poles when he received them. On April 15, 1996, when the repair station owner arrived at the Jomax site, he could not find anyone from the company. Later, he found a company driver and gave him the poles. The accident coordinates are 33 degrees 44.57 minutes north latitude, and 112 degrees 6.80 minutes west longitude. Crew Information The pilot held a commercial pilot certificate with a balloon rating. He did not hold a medical certificate, nor was he required to. Safety Board investigators did not review the pilot's flight hours logbook. The flight hours listed on page 3 of this report were provided by the pilot in the accident report. According to the accident report, the pilot accrued 1,795 flight hours in balloons, of which 1,768 hours were logged as pilot-in-command. During the preceding 90 days of the accident, the pilot accrued 67 hours as pilot-in-command. The pilot satisfactorily completed the last biennial flight review (BFR) on January 7, 1995. According to federal air regulations, a BFR is valid for 24 calendar months. Aircraft Information The FAA aircraft records section show that the balloon was registered to The Hot Air Balloon Company, Phoenix, Arizona. According to Get Carried Away company officials, the company purchased the accident balloon from the registered owner on April 5, 1996. At the time of the accident, the company did not reregister the balloon. Safety Board investigators did not recover the balloon's maintenance logbooks. According to the company's director of operations, the maintenance logbooks were aboard the balloon. Remnants of the logbooks were not found during the wreckage examination. A balloon pilot participating in the flight of four balloons told investigators that he accomplished the last annual inspection on April 3, 1996. He said that there were no deferred maintenance discrepancies when he completed the annual inspection. According to Cameron Balloons drawings CB 1006, issue I (April 2, 1996) and CB532, only nylon or lexan rods are permitted. The A-210 Cameron Balloon Flight Manual allows the balloon to be flown without any upright rods installed. If the upright rods are not installed, the pilot will use a different landing technique. That i ## Aircraft - Registration: [N6085C](https://openairdocs.org/deregistered/N6085C-1998-05-28), registration cancelled 1998-05-28, S/N 5458 (OpenAirDocs) - Reported make and model: Cameron A-210 - Registry model: [Cameron Balloons US A-210](https://openairdocs.org/model/cameron-balloons-us-a-210) (registry code 1880215) (OpenAirDocs) - Category: Balloon - Serial number: 5458 - Airframe hours: 640 - Engines: unknown - Damage: Destroyed - Fire: On-Ground - Flight: Part 91 - Registered owner: Getting Carried Away - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 3, 1996 - Departed: 8533, AZ ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; commercial; medical: unknown; flight hours: 1,795 total, 67 in the last 90 days, 23 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 8 knots - Visibility: 40 statute miles - Lowest ceiling: none - Temperature: 59 °F ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19960415007319A](https://openairdocs.org/incident/19960415007319A), Apr 15, 1996: Camron A210, Cave Creek, AZ, Destroyed, 2 fatal. Landing dragged 500FT tipped over and burned. Pass warned rough landing. Pilot failed to shut off pilot light. ## Docket (24 files) The files NTSB released with the investigation on June 27, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=29272. 2.0 MB in all. - Supplement s (item 1, PDF, 1 page, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14016758&FileExtension=pdf&FileName=Supplement%20S-Master-Rel.pdf - Pilot-operator aircraft accident report NTSB form 61201-2 (item 2, PDF, 7 pages, 307 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14026233&FileExtension=pdf&FileName=Pilot-Operator%20Aircraft%20Accident%20Report%20NTSB%20Form%2061201-2-Master-Rel.pdf - Factual report of group chairman-metallurgist (item 3, PDF, 2 pages, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025364&FileExtension=pdf&FileName=Factual%20Report%20of%20Group%20Chairman-Metallurgist-Master-Rel.pdf - Recorded notes of detective bryant phoenix pd (item 4, PDF, 2 pages, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14026236&FileExtension=pdf&FileName=Recorded%20Notes%20of%20Detective%20Bryant%20Phoenix%20PD-Master-Rel.pdf - Recorded interview -andrew waner (item 5, PDF, 3 pages, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025716&FileExtension=pdf&FileName=Recorded%20Interview-Andrew%20Waner-Master-Rel.pdf - Recorded interview -john bagwell (item 6, PDF, 2 pages, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025539&FileExtension=pdf&FileName=Recorded%20Interview-John%20Bagwell-Master-Rel.pdf - Robert romaneschi statement (item 7, PDF, 3 pages, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025543&FileExtension=pdf&FileName=Robert%20Romaneschi%20Statement-Master-Rel.pdf - Photographic wreckage diagram (item 8, PDF, 1 page, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14026112&FileExtension=pdf&FileName=Photographic%20Wreckage%20Diagram-Master-Rel.pdf - Balloon basket diagram (item 9, PDF, 1 page, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14026240&FileExtension=pdf&FileName=Balloon%20Basket%20Diagram-Master-Rel.pdf - Cameron balloons us investigation report (item 10, PDF, 5 pages, 366 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025492&FileExtension=pdf&FileName=Cameron%20Balloons%20US%20Investigation%20Report-Master-Rel.pdf - Excerpts of A-210 balloon flight manual (item 11, PDF, 5 pages, 292 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025720&FileExtension=pdf&FileName=Excerpts%20of%20A-210%20Balloon%20Flight%20Manual-Master-Rel.pdf - Aircraft bill of sale and purchase agreement (item 12, PDF, 2 pages, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025047&FileExtension=pdf&FileName=Aircraft%20Bill%20of%20Sale%20and%20Purchase%20Agreement-Master-Rel.pdf - Release of aircraft wreckage NTSB form 612015 (item 13, PDF, 1 page, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025372&FileExtension=pdf&FileName=Release%20of%20Aircraft%20Wreckage%20%20NTSB%20Form%20612015-Master-Rel.pdf - Photo 1 aerial view of main wreckage site (item 14, PDF, 1 page, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025724&FileExtension=pdf&FileName=Photo%201%20%20Aerial%20view%20of%20main%20wreckage%20site-Master-Rel.pdf - Photo 2 initial ground impact point viewing toward the northeast (item 15, PDF, 1 page, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025375&FileExtension=pdf&FileName=Photo%202%20%20Initial%20ground%20impact%20point%20viewing%20toward%20the%20northeast-Master-Rel.pdf - Photo 3 skid marks beginning from the main wreckage viewing toward the northeast (item 16, PDF, 1 page, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025050&FileExtension=pdf&FileName=Photo%203%20%20Skid%20marks%20beginning%20from%20the%20main%20wreckage%20viewing%20toward%20the%20northeast-Master-Rel.pdf - Photo 4 ground scar made when basket turned on its side (item 17, PDF, 1 page, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14026116&FileExtension=pdf&FileName=Photo%204%20%20Ground%20scar%20made%20when%20basket%20turned%20on%20its%20side-Master-Rel.pdf - Photo 5 overview of the main wreckage site (item 18, PDF, 1 page, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025546&FileExtension=pdf&FileName=Photo%205%20%20Overview%20of%20the%20main%20wreckage%20site-Master-Rel.pdf - Photo 6 basket frame and burner assembly (item 19, PDF, 1 page, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14026245&FileExtension=pdf&FileName=Photo%206%20%20Basket%20frame%20and%20burner%20assembly-Master-Rel.pdf - Photo 7 propane tanks (item 20, PDF, 1 page, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025054&FileExtension=pdf&FileName=Photo%207%20%20Propane%20tanks-Master-Rel.pdf - Photo 8 burners basket frame at examination facility (item 21, PDF, 1 page, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025379&FileExtension=pdf&FileName=Photo%208%20%20Burners%20basket%20frame%20at%20examination%20facility-Master-Rel.pdf - Photo 9 melted burner blast valve and pilot valve on position (item 22, PDF, 1 page, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025496&FileExtension=pdf&FileName=Photo%209%20%20Melted%20burner%20blast%20valve%20and%20pilot%20valve%20on%20position-Master-Rel.pdf - Photo 10 burner assembly note both pilot valves in the on position and the bent frame (item 23, PDF, 1 page, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14026052&FileExtension=pdf&FileName=Photo%2010%20%20Burner%20assembly%20note%20both%20pilot%20valves%20in%20the%20on%20position%20and%20the%20bent%20frame-Master-Rel.pdf - Photo 11 left burner ruptured propane line at manifold (item 24, PDF, 1 page, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14025383&FileExtension=pdf&FileName=Photo%2011%20%20Left%20burner%20ruptured%20propane%20line%20at%20manifold-Master-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.